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Julien, Anthony

MRN: 424697

Room: ED4

DOB: 12/01/1959

Age: 67

Gender: Male

Allergies: Levofloxacin (hives), lisinopril (cough)

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Emergency Department
Scenario	Please see clinical note. As a member of the patient’s care team, please address pharmacotherapy recommendations as well as other disease states to optimize this patient’s care in the hospital.
Admission note taken on 02/01/26
CC	“I have a fever, I cannot keep food down or urinate.”
HPI	Mr. Julien is a 67-year-old male who is presenting from home after being sent to the Emergency Department by his oncology case manager after contacting them for a new fever of 101.4°F (38.6°C) and inability to urinate in the past 24 hours. The patient recently started chemotherapy seven days ago for his newly diagnosed diffuse large B-cell lymphoma (DLBCL). He completed his last dose of a five-dose regimen of prednisone two nights ago. He mentions experiencing intractable nausea and vomiting with increased diarrhea frequency over the past few days. Mr. Julien endorses consistently taking his metoclopramide but has been having difficulty eating and sometimes vomits up his medications. The patient states he had not picked up his ondansetron ODT prescription yet. His significant other also mentions that the patient has been having difficulty sleeping and his blood glucose has been elevated for the past few days.
PMH	Diffuse Large B-Cell Lymphoma – diagnosed last month Started treatment with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) Premedications: palonosetron 0.25 mg IV x1, fosaprepitant 150 mg IV x1, dexamethasone 12 mg IV x1 Day 1 (12/1): rituximab 800 mg (375 mg/m2) IV x1, cyclophosphamide 1650 mg (750 mg/m2) IV x1, doxorubicin 110 mg (50 mg/m2) IV x1, and vincristine 2 mg (1.4 mg/m2, max 2 mg) IV x1 Days 1-5 (12/1-12/5): prednisone 100 mg PO daily Given every 3 weeks (x 6 cycles) Depression – diagnosed last month Hyperlipidemia – diagnosed last month Hypertension – diagnosed 9 years ago Chronic Kidney Disease Stage 3 – diagnosed 10 years ago Type II Diabetes Mellitus – diagnosed 14 years ago
Social History	Tobacco: none Alcohol: drinks 2 to 3 occasionally (beer) Recreational/Illicit drug use: none Occupation: Librarian (retired)	Family History	Mother (living) – Hypertension, Chronic Kidney Disease, Coronary Artery Disease Father (living) – Type II Diabetes Mellitus, Ischemic Stroke
Vaccine History	all childhood vaccines through age 18 Tdap: 8 years ago COVID-19: doses up to date per CDC guideliness Pneumococcal: doses up to date per CDC guidelines Influenza (inactivated): last season	Surgical History	Port placement (last month) Appendectomy (17 years ago)
Physical Exam	ROS Constitutional: Well-developed, well-nourished male. Follows commands. Fever, chills, and fatigue HEENT: No vision changes, ear pain, nasal symptoms, or sore throat Respiratory: No dyspnea with exertion; no cough CV: No palpitations, orthopnea, paroxysmal nocturnal dyspnea, or peripheral edema GI: Nausea, vomiting, and diarrhea GU: Unable to urinate in 24 hours MSK: No recent injury or immobilization Skin: No new rashes or skin lesions Neurological: Noncontributory Psychiatric: Not evaluated PE General: Elderly male, lying in bed with no acute distress Head: Two small white lesions inside the mouth on left cheek, mucous membranes show inflammation Eyes: Pupils equal and responsive to light Neck: Supple, symmetrical Neuro: Unremarkable Lungs: Decreased breath sounds bilaterally, crackles, and rales CV: Regular rhythm, tachycardic, no murmur or gallop Abdomen: Nondistended, nontender. No rebound/guarding. No hepatosplenomegaly. Skin: Dry, no external skin lesions, cuts, or bruises; Port site noted to be red and tender Extremities: Pulses present in all extremities, no edema, normal range of motion

Clinical Laboratory Report

Test Name	02/01/26	01/25/26	Range
Sodium (Na⁺)	140	135	136-145 mEq/L
Potassium (K⁺)	5.4	4.4	3.5-5 mEq/L
Chloride (Cl^-)	106	95	98-106 mEq/L
Bicarbonate (HCO₃^-)	22	23	23-28 mEq/L
Urea nitrogen (BUN)	31	9	8-20 mg/dL
Creatinine	3.3	1.4	0.5-1.3 mg/dL
Glucose	249	93	70-115 mg/dL
Hemoglobin A1c		6.7	5.3-7.5 %
Calcium,Total	6.7	8.0	8.6-10.2 mg/dL
Phosphate	5.6	2.4	3-4.5 mg/dL
Magnesium	2.3	1.9	1.6-2.6 mEq/L
Protein, total	5.4	5.5	5.5-9 g/dL
Albumin	3.0	3.7	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	24	24	10-40 units/L
Aminotransferase,alanine (ALT)	39	40	10-40 units/L
Lactic dehydrogenase (LDH)	650	900	80-225 units/L
Alkaline phosphatase	59	58	30-120 units/L
Bilirubin, Total	0.6	0.4	0.3-1 mg/dL
Leukocytes (WBC)	0.6	6.7	4.5-11 x10³/mcL
Red blood cells (RBC), Male	4.1	4.2	3.8-5.1 x10⁸/mcL
Hemoglobin, Male	11.2	13.1	14-18 g/dL
Hematocrit, Male	40	43	42-50 %
Mean corpuscular hemoglobin (MCH)	31	31	27-33 picogram
Mean corpuscular volume (MCV)	80	79	76-100 mcm³
Platelets	76	189	150-450 x10³/mcL
International normalized ratio (INR)	1.1	1.0	0.8-1.2
Prothrombin time (PT)	10.5	10.4	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	31	30	25-35 sec

Additional Labs:

Other Labs	Today	7 days ago
Uric Acid (mg/dL)	10.2	6.1
Serum alcohol (%)	0
Hepatitis B surface antigen (HBsAg)		Negative
Hepatitis B surface antibody (anti-HBs)		Positive
Hepatitis B core antibody (anti-HBc)		Negative

Fasting Lipid Panel (7 days ago)	Result
Total cholesterol (mg/dL)	154
LDL-C (mg/dL)	92
HDL (mg/dL)	40
Triglycerides (mg/dL)	112

CBC	Today	7 days ago
Segmented neutrophils (%)	10	50
Band neutrophils (%)	60	16
Lymphocytes (%)	25	30
Monocytes (%)	3	2
Eosinophils (%)	2	1
Basophils (%)	0	1
Absolute Neutrophil Count (cells/mm3)	420	4,422

Cultures:

Cultures (today)	Result
Blood cultures (two sets: left antecubital fossa and from port)	pending
Respiratory pathogen PCR panel	pending
Gastrointestinal pathogen PCR panel	pending
Pneumococcal urine antigen	pending
Legionella urine antigen	pending

Imaging Studies:

Diagnostic Tests (today)	Result
CTA thorax without contrast	Bibasilar atelectasis noted in both lungs. No evidence of pulmonary embolism.
CT abdomen and pelvis without contrast	pending
ECG	regular rhythm, QTc within normal limits

Vital Sign	02/01/26 09:25
Height (cm)	180
Weight (kg)	96
Body Temperature (°C)	38.9
Blood Pressure (mmHg)	89 / 65
Heart Rate (bpm)	110
Respiratory Rate (bpm)	19
Oxygen Saturation (%)	89

Current Orders

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES
			Pharmacy to dose consult ordered

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN nausea
CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES

Medication
History

The patient’s significant other brought the patient’s pillbox organizer to the ED.
The patient and significant other stated that he takes his medications as prescribed, but they are uncertain what pills he vomited up over the past several days.
He was using only metoclopramide for nausea and his diarrhea has worsened. He had been planning on discussing his diarrhea with his oncologist at his next appointment.
He was planning to pick up the ondansetron ODT prescription today.
Patient has not used any as needed OTC medications in the past 72 hours.

Home Medication List: verified by pharmacy on admit (02/01/26)

Patient Name: Julien, Anthony Date of Birth: 12/01/1959 Room#: ED4	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	NOTES	MED REC ACTION
Metoclopramide 10 mg tablet	1 PO QID	nausea
Sulfamethoxazole/ Trimethoprim 800 mg/160 mg tablet	1 PO 3x/week	no	takes on M/W/F
Allopurinol 100 tablet	1 PO QD x14 days	no	on day 7
Acyclovir 400 mg tablet	1 PO BID	no
Prednisone 100 mg tablet	1 PO QD x5 days	no	completed 2 days ago
Sertraline 50 mg tablet	1 PO QD	no
Insulin glargine 100 units/mL Pen	10 units SC QD	no
Losartan 50 mg tablet	1 PO QD	no
Amlodipine 10 mg tablet	1 PO QD	no
Cholecalciferol 1,000 units capsule	1 PO QD	no
Glipizide 10 mg tablet	1 PO QD	no
Turmeric 1,500 mg capsule	1 PO BID	no
Men’s multivitamin tablet	1 PO QD	no
Acetaminophen 500 mg caplet	1 PO QID	pain or fever
Ibuprofen 200 mg tablet	1-2 PO QID	pain or fever
				Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	02/01/26
Vancomycin 500 mg IV Q12H *Pharmacy to dose Rate: 100 mL/hr
Cefepime 1,000 mg IV Q24H Rate: 100 mL/hr
Sodium Chloride 0.9% Solution IV continuous, 75 mL/hr
Insulin glargine 10 units SC Q24H
Senna/Docusate 8.6 mg/50 mg PO Q12H
Enoxaparin 40 mg SC Q12H
Acyclovir 400 mg PO Q12H
Sulfamethoxazole/Trimethoprim 800 mg/160 mg PO 3x/week
Metoclopramide 10 mg IV Q6H PRN PRN nausea Rate: 1 mL/min

Clinical Notes

Emergency Department Notes:
--------------------------

Assessment: Fevers, laboratory results concerning for febrile neutropenia. Patient reported poor urine output and elevated serum creatinine concerning for acute kidney injury.

Plan: Patient to be admitted for intravenous antibiotics and oxygen due to MASCC score of 14. Plan to access port for inpatient use. Noted acute kidney injury to be treated with intravenous fluids.

Medication Discharge Orders

Hospital Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent

Previous Home Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent

Discharge Planning - Medication List and Instructions

Patient Name:
Admission Date:	Discharge Date:	Service:
Principle Diagnosis on Admission:
Secondary Diagnosis:
Allergies:

Medications ADDED this visit: (begin taking these)	Medications CHANGED this visit: (modify what you were taking)	Medications STOPPED this visit: (stop taking these)

Final Discharge Medication List
Medication/Route/Dosage/Frequency/Duration	Comments	Morning	Afternoon	Evening	Bedtime










As Needed Medications

Medication Reconciliation - Finalized Medication List

Patient Name: Julien, Anthony

Date of Birth: 12/01/1959

Room: ED4

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	180 cm
Actual Body Weight (ABW)	96 kg
Ideal Body Weight (IBW)	75.3 kg
ABW % of IBW	127 %
Adjusted Body Weight (AjBW)	83.6 kg
Body Surface Area (BSA)	2.19 m²
Body Mass Index (BMI)	29.6 kg/m²